• Nausea
• Treatment

• Some definitions are helpful.

  • Nausea is the feeling that vomiting might occur!
  • Vomiting is the forceful expulsion of gastric contents.
    • This is a complex and "automated" reflex action.
  • Retching is different from vomiting.
    • Gastric contents oscillate between the stomach and oesophagus.
  • Regurgitation is a symptom often confused with vomiting.
    • Food is brought back into the mouth without "effect".
    • Easy or “free” regurgitation worse on lying down or bending suggests severe gastro-oesophageal reflux rather than vomiting.
  • Regurgitation of undigested foods suggests partial oesophageal obstruction.
    • This can be due to a stricture (see heartburn) or tumour or from failure of relaxation of the lower oesophageal sphincter, as occurs in achalasia.
  • Anorexia is a loss of desire to eat.
    • This has a wide range of causes.
    • Including some gastro-intestinal diseases but also cancer, depression or metabolic disorders.
  • "The fear of eating" because of expected abdominal discomfort is a specific symptom which suggests small bowel obstruction.
  • A feeling of being full after eating a small quantity of food is different again.
    • Usually there is a normal appetite prior to starting a meal.
    • These symptoms are difficult to explain but are rarely due to any underlying problem.
    • Refer to section on indigestion and normal gastroscopy.
  • Chronic belching is a symptom mainly due to excessive swallowing of air which usually occurs during eating or drinking.
    • Excessive air swallowing may occur because of oral irritation or acid reflux.
    • Most commonly excessive air swallowing is due to anxiety or has become a habit.

Acute (sudden) onset of Nausea and Vomiting

• Vomiting of acute onset usually has associated symptoms that help make the diagnosis.
  • Acute vomiting associated with diarrhoea is likely to be due to gastroenteritis or food poisoning.
    • Symptoms of fever, muscle aches and headache may suggest viral gastroenteritis, particularly if other members of the family are affected.
  • Acute abdominal painis often associated with nausea and vomiting.
    • In this situation it is the nature of the pain rather than the presence of vomiting that is going to be most helpful in making a diagnosis.
  • Some conditions such as gallstone pain (biliary colic) are particularly associated with nausea and vomiting.
  • Nausea and vomiting associated with pain in the right upper abdomen suggests acute hepatitis.
  • Vomiting that has the smell of faeces and abdominal distension would suggest bowel obstruction.
  • Inner ear problems have the associated specific symptom of vertigo.


• For all of these situations – urgent medical attention is required for diagnosis then appropriate treatment.

Chronic Symptoms - lasting several weeks

Medications

• Many different drugs cause nausea - some examples are:
  • Digoxin and theophylline are commonly associated with nausea in the elderly.
    • These drugs may cause symptoms even if the drug levels are within the accepted range.
  • Many antibiotics cause nausea.
    • Erythromycin in particular may cause nausea and vomiting, together with pain in the right upper abdomen.
    • Flagyl and Tiberal are particularly likely to cause nausea and may also result in acute nausea and vomiting when taken with alcohol.
  • Anti-inflammatory drugs frequently cause nausea.
    • They may be causing an ulcer but can cause symptoms even when the stomach looks normal on examination by gastroscopy.

Non "Gut" Causes

• There are a number of non- "gut" causes of nausea and vomiting, but they are usually easily recognised.
  • Pregnancy results in morning nausea and vomiting.
    • Usually 8-14 weeks after the last menstrual period.
    • May continue throughout pregnancy.
  • Migraine is often distinguished from tension headache because of the associated nausea and vomiting.
  • Eating disorders such as bulimia.
    • Characterised by frequent binge eating and vomiting.
    • May also include use of laxatives and diuretics.

"Gut" Causes

• There are many causes of vomiting that relate to diseases of the oesophagus and stomach.
  • Vomiting that occurs immediately on awakening may suggest hazardous alcohol intake.
  • Vomiting non-digested food soon after meals suggests oesophageal disease such as achalasia or stricture.
  • Vomiting that occurs 3-4 hours after a meal, particularly associated with partially digested food, suggests blockage to the outlet of the stomach.
  • Anorexia, fullness in the upper abdomen and nausea usually has no underlying cause.
    • Rarely it may be a symptom of serious disease such as gastric ulcer or gastric carcinoma.
    • Examination by gastroscopy is recommended.


• Sudden forceful vomiting may result in traumatic tearing of the lining of the oesophagus.
  • This results in vomiting of blood.
  • This is the most common in the young person after excessive alcohol intake or during a gastroenteritis illness.


• Gastroscopy is the most helpful examination but will often be normal.

Treatment

• General treatment
  • Dehydration needs to be avoided using gastrolyte (best option) or sports fluids (Gatorade).
    • Drinking extra water is not adequate.
  • Drugs to stop vomiting may be given before a clear diagnosis is made.
    
• Medication for nausea and vomiting.
  • Many different medications are available for treatment.
  • The choice is usually related to ease of use, the possible side-effects, and also whether one medication has some helpful additional effects.
  • Prochlorperazine (Stemetil) acts directly on the vomiting centre in the brain.
    • The main side-effects are unwanted sedation and rarely muscle spasms.
    • This drug is used widely for treatment of nausea and vomiting from many different causes.
    • Stemetil is available as a tablet and suppository (rectal) and a buccal preparation called Buccastem - placed between the lips and the gums (available directly from the chemist).
  • Metoclopramide (Maxalon) and domperidone (Motilium) act by stimulating gut motility and accelerating gastric emptying.
    • Metoclopramide should be avoided in children and the elderly.
    • Metoclopramide has some particular use in the treatment of migraine, as delayed emptying of the stomach is part of the spectrum of this illness.
    • These drugs are useful if fullness and bloating after meals are a major part of the symptoms.
  • The anti-cholinergic drugs, e.g., atropine hyoscine, or cyclizine (Marzine) are used mainly for the prevention of motion sickness.
    • Drying of the mouth and blurred vision are common side-effects which reduces their acceptability.
    • Scopolamine (Scopaderm), a transdermal preparation, appears to be more acceptable.
    • Cyclizine is useful for motion sickness but also for other causes of nausea.
  • Chemotherapy sometimes causes severe nausea.
    • Zofran (ondansetron) is very effective particularly if given early.
    • It is sometimes used for post-operative nausea.